This post is the second in a two-part series exploring the potential and realized impact of the COVID-19 on maternal health. The first post focused on the United States, while this takes a more global approach.
COVID-19 continues to spread across the globe, and the death toll is nearing a half a million. As the pandemic progresses, the situation worsens in several low- and middle-income countries (LMICs), including India and Brazil. At the same time, more recent hotspots have cropped up in Peru, Nigeria, and Mexico, among others. In addition to the direct health effects on pregnant and parenting women infected with COVID-19, the unprecedented lockdowns affecting entire countries, the subsequent economic downturn, and public fear associated with contracting the virus, have put the security of mothers and their children at stake. The maternal health community must remain vigilant in identifying and mitigating threats to maternal health as they emerge to ensure that mothers and children do not suffer unnecessarily.
Since our last post on COVID–19 in the United States, more evidence has emerged on the potential direct effects of a COVID-19 infection during pregnancy on the health of pregnant women and their infants. Emerging studies, while largely supporting previous evidence that pregnant women are at much lower risk than the elderly, have found worrying sequelae specific to pregnant women with COVID-19 infections, such as placental injury and a pre-eclampsia like syndrome. Yet, the true clinical importance of these findings is not known. Furthermore, the prevalence in both high- and low-income countries, seems low. Complicating the picture for LMICs, almost all estimates of death and severe disease rates in pregnant women have come from countries with robust and well-funded health care systems. Emerging evidence from India, Brazil, and Mexico suggests direct effects of COVID-19 infections among pregnant women may be more severe in areas with low access to medical facilities, ventilators, or trained clinicians and where other infectious diseases and malnutrition are more common.
While controlling COVID-19 is certainly a priority for public health, for maternal health the indirect effects of the pandemic are likely to be even more devastating. A recent study modeling potential excess maternal and under 5 child deaths due to loss of coverage of essential maternal and child health interventions suggested, in the best-case scenario, we’d see 42,240 additional child deaths and 2,030 additional maternal deaths worldwide every month. Interrupted access to life-saving maternal health interventions is almost certainly occurring. Concerning reports are emerging from India on steep declines in facility-based birth during the country’s strict lockdown, both due to fear of contracting novel coronavirus among birthing women and their families, inability to secure transportation to facilities, and more recently limited capacity at overwhelmed hospitals. In Nigeria, where coronavirus is largely spreading unchecked, hospitals have been forced to stop accepting patients as staff have become infected and the hospitals themselves overwhelmed. Recent reporting from the New York Times has highlighted the deaths of at least two women in labor turned away from beleaguered hospitals in India; in one case a woman was denied entry at eight hospitals before she died.
Government measures to control infection, particularly stay-at-home orders, have unintentionally put women and children in LMICs at risk of poverty, hunger, and violence. Large portions of many LMICs’ GDP are based in the informal economy; 65% of Nigeria’s GDP in 2017 and over 80% of those employed in India are in the informal sector. Stay-at-home orders and other similar policies are likely to particularly affect those in the informal sector, who do not have access to the ability to work remotely or to rely on employment-based relief. While the U.S. and other higher-income countries have been able to provide economic relief packages in the trillions, many low and middle income countries do not have the capacity to provide economic relief to the majority of citizens. Stay-at-home orders swiftly ended the ability of many to earn income, threatening hunger in populations already suffering from malnutrition.
In several countries, stay-at-home orders forced the mass exodus of migrant workers, many of them women, from the cities to their rural homes, exacerbating the spread of infection among rural families. In India, migrant workers have been forced to walk or take unsafe transportation to reach their villages or face homelessness and starvation in the cities, and deaths along the road are not uncommon. In some cases, this exodus was forced, as in Nigeria where tens of thousands of children attending Quranic schools were forcibly removed to their villages. Many of the children had active COVID-19 infections.
The combination of increased stress, more time with family, and a reduction of services for those fleeing domestic violence is leading experts across the world to predict a “shadow pandemic” of domestic and gender-based violence. Contact with those seeking help in situations of domestic violence have increased in several higher-income countries including Spain, China, France, and Italy. Reports from middle-income countries are also increasing, including Ukraine, where UNFPA hotlines registered a 113% increase in clients. Data from most low-income countries has yet to show any specific trends, but over time are expected to also increase. The U.N. Family Planning Association estimates that for every three months that lockdowns continue, an additional 15 million cases of violence are anticipated around the world.
As short-term measures to control infection end or are loosened, the long-term setbacks will become clear. Interruptions in the supply chain of needed medications and contraceptives and diversion of funds or healthcare personnel from routine sexual and reproductive and maternal healthcare, even if brief, have downstream consequences on the number of unintended pregnancies, unsafe abortions, and maternal morbidity and mortality, although the magnitude of any downstream consequences remain unclear. Furthermore, the downturn in the global economy is sure to affect both the spending power of individual women and their families and the available funds for large-scale maternal and child health interventions, both within countries and from foreign aid. The degree of setback in maternal health indicators will depend on whether and how governments and maternal health professionals fight to keep maternal health a priority during the crisis and beyond.
First, any large-scale policy efforts to slow the spread of COVID-19 must be developed and implemented with the needs of families, especially the most vulnerable, in mind. Balancing the need to implement and enforce stay-at-home orders with other health priorities means clear guidance and communication on the part of governments, relief for those most severely impacted by the shut downs, and the retention of healthcare workers able to respond to routine and emergency maternal health needs. Second, as countries begin the process of re-opening their economies, they must also focus on the support of healthcare supply chains, maternal health programs, and vaccination schemes to prevent a rise in maternal mortality and a resurgence of vaccine-preventable diseases. Finally, maternal health must not be forgotten as we move towards a post-pandemic world. Otherwise, we threaten the lives of hundreds of thousands of women and their children already at risk of poor health and premature death.